Promises to keep The Toll of Unintended Pregnancies on Women’s Lives in the Developing World
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Published by the Global Health Council with support from the David and Lucile Packard Foundation
Authors: Nils Daulaire, M.D., M.P.H. Pat Leidl, M.A. Laurel Mackin, M.A. Colleen Murphy Laura Stark, M.Sc. Ph.D.
Š Copyright 2002 by the Global Health Council. All rights reserved.
Nearly 200 million women become pregnant around the world each year. The United Nations estimates that one-third of these pregnancies are unintended and unwanted.1 Of these, many result in the death of the mother. How many women would be alive today if contraceptives and family planning services had been available to prevent these pregnancies? Thanks to a grant from the David and Lucile Packard Foundation, the Global Health Council has compiled a statistical analysis designed to detail the cost in women’s lives and health as a result of unintended pregnancy. At the 1994 International Conference on Population and Development (ICPD) in Cairo, 179 nations pledged to improve the health of the world’s women. How well has the world done in meeting this commitment? While the goal of this analysis is to provide an accurate metric for assessing the consequences of unintended pregnancy, it should not be forgotten that every statistic included represents the life of a woman or girl, a wife, a mother, a daughter or a sister. These statistics, and the lives they represent, shed light on a hidden and intransigent epidemic of premature death and disability that plays itself out in thousands of communities every minute of every day. The women, whose lives are represented in the analysis detailed in this report, and whose stories appear throughout this document, were victims of a twofold tragedy: they wanted to avoid pregnancy and they wanted to live. It is a somber reflection of the world’s priorities that they were unable to do either.
1 N. Sadik, The State of World Population 1997, UNFPA, New York, 1997.
"I had been working in a rural clinic in Bangladesh for just a few weeks when they brought her to us. She had been carried for hours on an oxcart from her village, and it was obvious that she was in very serious condition. We learned that she was 19, married at 15, already had two children, and had started active labor six days earlier. She had been attended at home by a traditional birth attendant, but had become exhausted from pushing and the baby had stopped moving. For the last two days she had developed an increasingly high fever. It was only when she seemed close to death that her husband decided to bring her to the clinic. When I examined her, it was immediately obvious that the fetus had died and started to putrefy inside her. She was unconscious and had a raging fever. We whisked her into the operating theater for an emergency delivery but we no sooner had her on the table than she had a seizure, started frothing at the mouth, and stopped breathing. Our efforts to resuscitate her were fruitless. She was the first woman I had ever seen die in childbirth. I went outside to talk to her husband and her sister. Her husband said he could not take her body for burial with the child inside it, so I returned to do a postmortem delivery. I discovered that the decomposing baby was in her abdominal cavity – her uterus, weakened from early and successive pregnancies, had obviously ruptured during labor. When I went back out to tell the husband I had completed this task he asked me if it had been a boy child; both the previous children were girls and he had wanted her to bear him a son. When I said that as best I could tell it was not, he said that in that case it was probably just as well – his wife could only have given him more girl children. With the husband busy with preparing his wife’s body for transportation back to the village, I turned to the sister and asked why the woman had chosen to have so many children so closely spaced and why she hadn’t considered family planning. Her sister, shyly, said that she knew her sister did not want to be pregnant again, but that these things were in the hands of God and of her husband. There was nothing she could have done to prevent it.” — Source: Dr. Nils Daulaire, report from Gonoshasthaya Kendra, Bangladesh, 1976
CHAPTER ONE The widening gap This story is not an isolated event. Every minute, somewhere in the world, a woman is either dying from, or suffering the effects of a pregnancy that was unplanned and, in many instances, unwanted. These deaths and the accompanying social and economic costs are almost entirely avoidable; they are the result of poverty, ignorance, social and economic marginalization, entrenched gender bias, and inadequate access to effective family planning services.
The promise In September of 1994, the United Nations International Conference on Population and Development (ICPD) met in Cairo to address issues of population growth and sustainable development. Twenty thousand government delegates, UN representatives, NGOs and members of the media attended the nine-day conference to address a number of critical (and often controversial) issues, including immigration policy, reproductive health, reproductive rights, the empowerment of women, urbanization and access to health care. During the conference, delegates negotiated a 16-chapter Programme of Action that set out a series of recommended actions targeting population and development. Included was a pledge from 179 nations to transform and fund reproductive health services around the world. From what had previously been characterized as a narrow emphasis on population control through contraception – in effect, the rich telling the poor how to control their fertility – delegates expanded the conventional definition of "reproductive health" to include: A state of complete physical, mental and social well-being and not merely the absence of infirmity, in all matters related to the reproductive system and to its functions and processes.2 They went on to state: Reproductive health, therefore, implies that people are able to have a satisfying and safe sex life and they have the capability to reproduce and they have the freedom to decide if, when and how often to do so. Implicit in this last condition are the right of men and women to be informed and to have access to safe, effective, affordable and acceptable methods of family planning of their choice, as well as other methods for the regulation of fertility which are not against the law, and the right of access to appropriate health-care services that will enable women to go safely through pregnancy and childbirth and provide couples with the best chance of having a healthy infant. At the ICPD, delegate nations made a commitment to generate the estimated U.S. $17 billion per year required to meet the reproductive health needs of the world’s women, with onethird to be provided by donor nations. Also contained in the commitment were assurances that everyone who wished to limit or space their children could do so with appropriate access to family planning services. What is maternal mortality? The World Health Organization defines maternal mortality as: …death of a woman while pregnant or within 42 days of termination of pregnancy,
regardless of the site or duration of pregnancy, from any cause related to or aggravated by the pregnancy or its management. Maternal deaths are subdivided into direct and indirect obstetric deaths. Direct obstetric deaths result from obstetric complications of pregnancy, labour, or the postpartum period. They are usually due to five major causes – hemorrhage (usually occurring postpartum), sepsis, eclampsia, obstructed labour and the complications of unsafe abortion – as well as interventions, omissions, incorrect treatment or events resulting from these. Indirect obstetric deaths result from previously existing diseases or from diseases arising during pregnancy (but without direct obstetric causes), which are aggravated by the physiological effects of pregnancy; examples of such diseases include malaria, anemia, HIV/AIDS and cardiovascular disease.3 A recent study undertaken by Save the Children points to an indisputable correlation between maternal mortality and inadequate access to quality reproductive health services.4 This finding has been confirmed by similar studies around the globe, which clearly demonstrate that maternal mortality is highest in countries where women are least likely to have access to modern contraceptive methods. In Burkina Faso, for example, where only 4 percent of women use modern family planning methods, one in 14 will die of maternal causes over the course of her lifetime. In Brazil the opposite is true: nearly three-quarters of the female population regularly use family planning services and their lifetime risk of maternal mortality sinks to one in 130. The current reality With support from the David and Lucile Packard Foundation, the Global Health Council has undertaken a statistical analysis designed to produce a measure for assessing progress made toward the achievement of 1994 ICPD goals – particularly as they pertain to the health and survival of women. The study was designed to determine whether the further extension of family planning services might play a significant role in reducing deaths of women due to pregnancy and childbirth. The analysis revealed that in the six years following the Cairo ICPD (1995-2000), the world’s 1.3 billion women of childbearing age experienced a total of more than 1.2 billion pregnancies. Of these, more than 300 million – or more than one-quarter – were unintended. During this six-year time period, nearly 700,000 women lost their lives as a result of these unintended and unwanted pregnancies. More than one-third died from the myriad problems associated with pregnancy, labor and delivery. The majority – more than 400,000 – died as a result of complications resulting from abortions carried out in unsafe, unsanitary and often illegal conditions. Furthermore, while the Global Health Council’s figures show the number of live births has stabilized at around 131 million per year worldwide, they also reveal that the number of women dying each year as a result of unintended pregnancy has increased. The reasons for this continued prevalence of maternal mortality are manifold, including social and political upheaval in regions throughout the world, flagging funding for essential services, and the widening HIV/AIDS epidemic. The figures also reflect the failure of the international community to live up to the ICPD commitments made to the world’s women assuring access to the reproductive health and family planning services that could readily reverse these terrible facts. The figures cited in this report are evidence of a serious health crisis, one that will only deepen as more women move into their prime reproductive years. Over the next decade, 600 million girls will become adolescents, the largest cohort of young women in human history. The worsening condition of women’s health could be slowed or even halted if their survival became a global priority in action, as well as words.
2 ICPD Programme of Action, 1994. 3 WHO, Maternal Mortality, 1993. 4 Save the Children, State of the World’s Mothers, 2000, p. 16.
CHAPTER TWO ANALYSIS AND RESULTS There are a number of methodological challenges when it comes to compiling data on the relationship between unintended pregnancy and maternal mortality. Countries burdened with the highest mortality rates often have inadequate medical, census and survey data. Intention is always difficult to establish, particularly when it pertains to something as personal and intimate as pregnancy. Induced abortion in many countries and societies is considered both shameful and illegal, and is, therefore, not readily reported. Our aim in conducting this analysis was to calculate the number of women who died during the six-year period between Jan. 1, 1995, and Dec. 31, 2000, as a result of pregnancies that were unintended and unwanted. This time period was selected because it marked the first full year after the ICPD highlighted maternal deaths as an important social and public health issue, and because a six-year time frame should be sufficient for researchers to detect demographic trends. Based on the best available statistics from the U.S. Census Bureau, UN agencies, reports from the countries themselves, and specialized surveys carried out by a variety of respected research organizations, the Global Health Council compiled a country-by-country profile of all 227 countries for the calendar years 1995 through 2000. For each country and each year, data were generated on the number of pregnancies, the number that ended in miscarriage and abortion, and the number carried to term. For each of these, the Council relied on data sources to calculate the numbers that resulted from unintended pregnancies, those that resulted in the death of the woman, and those carried to term. Detailed data and its sources are found in the appendix to this report. It is important to note however, that "pregnancy" and "birth" are not synonymous. Pregnancies included those that were miscarried, aborted or carried to term. Ultimately, we calculated estimates of the births that were the consequence of unintended and unwanted pregnancies and that resulted in a mother’s death. Our figures reflect the following constraints: • In compiling the data, we used only the rates on unintended pregnancies, excluding those that are mistimed, even though the mistimed pregnancies could be characterized as unintended; had we included the latter, the number of associated maternal deaths would have been considerably higher. • We did not estimate the number of maternal deaths from unintended pregnancies that ended in miscarriage. Reporting problems and uncertain diagnostics make miscarriage data particularly hard to verify. • The fact that abortion is widely illegal and, therefore, under-reported for fear of legal consequences contributes to mis-reporting and to under-reporting of abortion complications. Reported abortion rates by country is the starting point for this analysis (the data itself assumes that all abortions are the result of unintended pregnancies). To this figure was added the number of mothers’ deaths from unwanted births, gleaned through a country-by-country review of data from the Demographic and Health Surveys.5 It was assumed that women who carried unintended pregnancies to term had the same mortality risk as the population of mothers at large. Thus, the overall maternal mortality ratio – subtracting the proportion of that mortality associated with abortions – was applied to the proportion of unwanted births. The number of mothers’ deaths
from unwanted births added to women’s deaths from abortions was totaled to derive a conservative estimate of the number of maternal deaths from unintended pregnancies. Data for this project were calculated from numerous primary and secondary sources. Some data (such as the population and birth rates) were available by calendar year. Other data (such as the maternal mortality ratio, percentage of births that were unwanted, and abortion rates) were available only as a constant figure for the entire time period involved because the surveys upon which they were based were not conducted annually. In a few cases, national data were not available to account for some variables. In these instances, projections were based on regional averages or from rates from neighboring countries and those with comparable profiles. Based on primary data, separate tables were developed for each of the six calendar years included in the study. Countries were arrayed according to seven geographic regions: Africa, Latin America/Caribbean, North America, Near East, Europe, Asia, and the Developed Pacific. Based on the primary data, figures were calculated according to the number of live births, abortions (wherever primary country data were not available), fetal wastage, total number of pregnancies, total maternal deaths, abortion-related maternal deaths, non-abortion-related maternal deaths, unintended pregnancies, unwanted births, deaths resulting from unintended pregnancies excluding abortions, and total deaths resulting from unintended pregnancies. Data for each country and region were then compiled for the entire six-year period. Results Summary Unintended pregnancies The analysis reveals that, in the six years from January 1995 through December 2000, the world’s nearly 1.4 billion women between the ages of 15 and 45 experienced a total of more than 1.2 billion pregnancies. Of these, at least 338 million pregnancies (28 percent) were unintended or unwanted. The proportion of unintended pregnancies in each geographic region is shown in Table One. Demographers note that, as countries move through the transition from highly traditional and economically underdeveloped societies to those more economically developed and socially integrated with the rest of the world, an upward curve in the middle stages of this process typically appears in both the proportion and the number of unintended pregnancies. In countries where societal norms favor large families, the early development stage is generally characterized by continued desire for many children and a reluctance to consider any births as "unwanted." In Africa, for example, a relatively small proportion of pregnancies (see Table One) are considered "unintended" despite the continent’s high fertility rate. As social conditions and attitudes change, often a lag time occurs between the desire for fewer children and the achievement of those aims. The "mid-development" nations of Latin America and the former Soviet Union characterize this with considerably higher levels of "unwantedness" despite increased access to family planning. As a result of widespread access to quality family planning, more economically developed nations such as those in Western Europe, the Developed Pacific and North America show a decline in “unwantedness” in a direct relationship with a high level of family planning. Women’s deaths as a result of unintended pregnancies: The analysis shows that during this six-year period, almost 700,000 women died because of an inability to appropriately space, plan for, and prevent their pregnancies. These deaths comprised more than one-fifth of all maternal mortality during this period. Furthermore, the number of women dying as a result of unintended pregnancies was shown to have in fact increased somewhat during the course of the six years evaluated. Although the numbers have remained fairly stable on a global scale, marked increases occurred in certain regions of the world, particularly in Africa, as seen in Figure One.
The toll of unsafe abortion Where women have little or no access to simple and reliable methods of contraception, an unintended pregnancy often leads to the decision to have an abortion. Our data confirm that during this period nearly three-quarters of unintended pregnancies worldwide were terminated, resulting in more than a quarter of a billion abortions. In no region of the world were even half of unintended pregnancies carried to term (see Table Three). The Near East came closest, with 55 percent of unintended pregnancies resulting in abortions and 45 percent carried to term. Equally striking is the clear indication that prevailing legal and religious strictures apparently had relatively little – if any – effect on recourse to abortion. Latin America, which has some of the strictest abortion laws in the world, nonetheless, saw nearly a quarter of all pregnancies terminated by abortion. Even higher levels in the former Soviet states would indicate that family planning services have, as yet, made only limited inroads there. Globally, the data confirm that nearly 14 percent of all maternal deaths – one out of seven – are the result of abortion complications. National data analyzed herein clearly demonstrate that in countries where women desire to limit their families, and have access to adequate family planning services, the number of women both seeking abortions and dying as a result of them remains relatively low. In contrast, where women do not wish to have additional children but are unable to access quality health care and family planning services, both the number of abortions and the likelihood of dying from complications stemming from the procedure rise sharply. Even where women favor large families – but still have only limited access to reproductive services – mortality rates resulting from abortion remain extremely high. Maternal mortality as a consequence of abortion is directly associated with conditions of poor reproductive health services. The data show that women living in countries with the most limited services – notably in sub-Saharan Africa and South Asia – are those who suffer the highest risk of abortion-related death, despite their relatively lower level of unintended pregnancies (See Figure Two, p. 14 ). Clearly, regardless of whether or not these women wished to be pregnant, it is they who pay the price for a failure to meet the commitments of the ICPD. Unintended Pregnancy and Maternal Mortality “Seven years ago Mili’s sister Sundari became pregnant for the twelfth time. Sundari’s pregnancy – unexpected and unwanted – was uneventful up until the eighth month. One night she awoke bleeding profusely and in great pain. Sundari’s family called in a traditional birth attendant, who undertook a cursory examination only to announce that the 35-year-old woman should be taken to the hospital immediately. Unfortunately, by this time it was one o’clock in the morning; no transport was available. Bleeding and by now in great anguish, Sundari paced restlessly all night until morning. Sometime early in the morning a "compounder" was brought in who pronounced Sundari to be "beyond treatment." He overruled the traditional birth attendant, instructed the family to forgo an expensive hospital stay and persuaded the family that as a medical doctor, his decision should take precedence. While the family argued and agonized, Sundari continued to bleed. By mid-afternoon she was dead. To this date, Sundari’s sister Mili blames herself for failing to bring her sister to the hospital. She cannot bear to look at the seven children (four had died in infancy) left behind.” — Source: Mili Begum, UNICEF Bangladesh
According to the data presented in this report, more than one out of every four pregnancies that take place around the world each year is unintended. While more than two-thirds of these end in abortion, often at the cost of the woman’s life, a very large number are carried to term. Over the course of this study nearly 88 million children were born as the result of unintended pregnancy. While this does not necessarily mean that these children will not be loved or cared for, there is clear evidence that children resulting from such births face considerably higher disease and premature death rates. It is noteworthy that this number is more than twice the figure of 40 million AIDS orphans predicted by the year 2015, with the enormous social consequences this portends.6 These children, and their families, face another hazard; namely, nearly a quarter of a million of their mothers did not survive childbirth. Again, women living in the most underprivileged circumstances bore the highest risk. The reasons for this epidemic of unintended pregnancies are as diverse as the human condition. Poverty, ill health, fear of social ostracism, displacement, rape, incest, maternal depletion/exhaustion and mothers who are either too young or too old to carry a child safely to term are just a very few of the reasons why women seek to limit the number of children born to them. Indeed, the greatest burden on a woman’s health during her young adult years is reproductive in origin. Whether she dies or suffers serious disability as a result of pregnancy is directly correlated to whether she is able to access quality health care and family planning services. While the high levels of unintended and unwanted pregnancies cited in this report have been recognized by the public health community for some time, this analysis presents country-bycountry data that, for the first time, highlights this issue from a global perspective. This analysis demonstrates that family planning can save lives and improve health. Failure to provide women with the means to prevent unintended pregnancy poses an extraordinary public health threat, one that could readily be addressed with modest resources.
5 Ross, Stover, Willard, Profiles for Family Planning and Reproductive Health Programs, Table A.16., 1996. 6 UNAIDS, 2000.
CHAPTER THREE Beyond Mortality “My dear friend Rina has given birth to eight children, but only three of them survived childhood. On her third delivery her uterus prolapsed but she could not afford the surgery to correct the problem. During the next five years she gave birth to five babies and with each birth the pain got increasingly worse. After her eighth delivery, a part of her uterus fell out and could not be pushed back in. My friend is a hard-working person. She used to be able to do heavy household jobs but can now no longer lift anything heavy. Because of her slowness around the house and sexual problems with her husband, her marriage has become increasingly strained and difficult. At the age of 38, Rina has become seriously disabled.” — Source: Shuchitra Mallik, UNICEF Bangladesh According to the World Health Organization, for every maternal death an estimated 30 additional women suffer pregnancy-related health problems that are frequently permanently debilitating.7 Each year an estimated 17 million women suffer uterine rupture, prolapse, hemorrhage, vaginal tearing, urinary incontinence, pelvic inflammatory disease and obstetric fistula, a muscle tear that allows urine or feces to seep into the vagina. These and other chronic conditions are more likely to occur in women who are on the cusp of childbearing years – either very young or very old – are suffering poor health, malnutrition or have given birth to a number of children already. Not only do these and other disabilities lead to social and economic isolation, they also increase the risk of maternal mortality during and after subsequent pregnancies. The costs to family and community, while beyond the scope of this analysis, are correspondingly severe. Social costs Statistics related to maternal death, of course, are only indicators of the profoundly disruptive social, economic and emotional cost levied on families and communities owing to the loss of a mother. A mother’s death can in many instances have a far greater impact on the family and community than the death of a child, a septuagenarian or even a father. The death of the mother is very often the death of the household. In developing nations, where an estimated 98 percent of adult deaths relating to poor reproductive health services take place8, the loss of a mother translates into the increased likelihood that surviving family will not be able to properly care for existing children. As a result, children of deceased mothers are frequently farmed out to relatives or are forced out on the street. In addition, young children whose mothers have died run a much greater risk of dying themselves.9 Because the women whose lives are lost are typically between the ages of 15 and 45, elevated levels of maternal mortality represent a significant threat to the broader socio-economic systems in which these deaths occur. Women not only serve as the primary educators of their families, they are also typically the primary caregivers of both young and old. It is women, moreover, who are often the main, if not the sole, breadwinners in their families. Preventing Unintended Pregnancies: Costs and Benefits The World Health Organization and the World Bank estimate that US $3 per person per year would provide basic family planning, maternal and neonatal health care to women in developing countries. This package would include prenatal, delivery and post-natal care in addition to postpartum family planning and the promotion of condoms to prevent sexually transmitted infections. 10 Investment benefits can be measured in a number of ways. The simplest metric is in the number of women’s lives saved as a result of access to appropriate health-care services. What is not immediately apparent, however, is the benefit extended to her family, her community and society at
large. By the very fact of her preserved life and health, a woman who has the means to regulate her own fertility has a greater likelihood of obtaining an education and is more likely to contribute to the social and economic well-being of her family. If already a mother, she will continue to devote time and energy to existing children or other dependents. Finally, she is much more likely to space subsequent births accordingly. This ability to plan for additional children is something that benefits both mother and child. Studies show births too closely spaced not only endanger the mother’s life, but children born to such mothers face higher rates of malnutrition and an increased rate of childhood mortality. 11 What is a boon for the family is also of benefit to the economy as a whole. Studies undertaken by anthropologist Sidney Schuler suggest that new strategies for promoting reproductive health services in Bangladesh are helping to loosen the traditional social strictures that kept women isolated within their homes and, therefore, limited their opportunities and their potential contributions to the economy and society. 12 Indeed, female productivity generates economic activity that has the potential to benefit all. The obverse constitutes a serious hindrance to development that undermines local, regional and national economic aspirations. Regional Disparities Many regions of the world have witnessed distinct progress in the provision to women of comprehensive reproductive health and family planning services. Contraceptive use has increased tenfold in developing countries, and other regions have undertaken reforms designed to increase access to quality prenatal and antenatal care. Despite this progress, there is a growing disparity between the health care available in industrialized nations and that which is available in the developing world. At present, women in some developing nations run several hundred times the risk of dying in pregnancy and childbirth compared to their counterparts in wealthier nations. In North America and Europe, one woman in 4,000 is likely to die from maternal causes. In Africa, one of every 15 women will die of these causes.
7 WHO, Unsafe Abortion, 1997, p. 3. 8 Population Action International, A World of Difference, 2000, p. 3. 9 Taylor ME, Analysis of Systems: The Jumla Community Health Program, 2000. 10 WHO/UNFPA/UNICEF/World Bank Statement, Reduction of Maternal Mortality, 1999. 11 UNICEF, State of the World’s Children, 2000. 12 Schuler, SR, Bates, L, Khairul Islam, M; Reconciling Cost Recovery with Health Equity Concerns in a Context of Gender Inequality and Poverty; International Family Planning Perspectives, vol. 28, no. 4, forthcoming, 2002.
CHAPTER FOUR RISK FACTORS It is most often the poor and illiterate who pay the highest price for inadequate reproductive services; they do so with their lives, broken families, poverty, social isolation and chronic ill health. The human toll exacted from unintended and unwanted pregnancies is typically a hidden one, buried under often age-old social norms governing the roles of women in society. Economic marginalization, poor education, and geographical isolation contribute further to inconsistent reportage, but are by no means the only indicators of high maternal mortality rates. Indeed, wealth alone does not ensure adequate reproductive health care for women. Lack of Commitment from Governments According to Save The Children’s "Mother’s Index," Kuwait’s annual GDP ranks third in the world. Yet the wealthy Gulf kingdom ranks 50th in the world with respect to overall maternal health.13 In striking contrast, Costa Rica – with its modest average income of U.S. $6,650 – ranked in 12th place for mothers and 8th for children. UNICEF speculates that strong government support for equitable health care and education, as well as emphasis on modern and affordable contraception, has much to do with Costa Rica’s standing.14 Since the 1970s, the government has invested 7 to 8 percent of its GDP in the public health sector. Fully 65 percent of women choose to use modern contraception, while an additional 10 percent rely on other forms of family planning such as the rhythm method. Donor governments also enter into this equation. For instance, the United States has been for many years the largest donor to international family planning and reproductive health programs. In the federal budget passed in 1994 (the same year as the ICPD), the total U.S. contribution to these programs reached $585 million. The federal budget enacted by Congress six years later provided $415 million for the same purposes. The inevitable result has been cutbacks at a time when the world seemed prepared to move forward. Youth “Hamida’s parents married her off at the age of 13. Within two months, she became pregnant but almost immediately began experiencing violent bouts of morning sickness that made it impossible for her to keep anything down. After finally seeing a doctor, Hamida’s condition improved somewhat and she was able to resume work in the fields. Her eighth month of pregnancy, however, proved difficult and she again fell ill and was hospitalized for two weeks. In due time, Hamida went into labor. Her family called for a nurse who in turn advised them that Hamida’s condition was critical and that they must move her to a hospital right away. Once there, the attending doctor performed a quick examination and informed the family that, owing to Hamida’s youth and small size, she must undergo a Caesarean section and would require blood for a transfusion. While Hamida’s husband went in search of blood, the attending physician realized he could no longer put off surgery and went ahead. Hamida’s husband returned with blood but it was too late. Both his wife and child were dead.” — Source: UNICEF, Bangladesh
The story of Hamida is not an unusual one in areas of the world where marriage at the age of 12 or 13 is common practice. At this stage of a girl's life, her growth is usually incomplete and her body not sufficiently mature to allow for easy delivery. Pregnancy, therefore, is often very dangerous. Studies undertaken in Jamaica and Nigeria found girls younger than 15 are four to eight times more likely to die during pregnancy or delivery than women aged 15 to 19.15 Those who survive are more likely to suffer serious bodily harm leading to chronic conditions such as obstetric fistula, vaginal tearing and incontinence. Their offspring are more likely to be born underweight and are, therefore, more vulnerable to increased rates of childhood disease and mortality. Many women living in developing countries give birth to their first child before they reach the age of 18. Throughout most of sub-Saharan Africa, Bangladesh, India and in impoverished Guatemala, 25 to 43 percent of women now aged 20 to 24 delivered their first child before their 18th birthday.16 If a pregnant teenager is unmarried, she will face even greater risks – family shame and societal disapproval prevent many such girls from seeking any kind of care during pregnancy. For these and other reasons, both social and economic, very young women are less likely to access quality prenatal care than are older mothers and, therefore, are more likely to seek unsafe abortions. The risk factor further increases among this population due to nutritional deficiencies, widespread in most developing countries. These and other factors exacerbate the problem of stunted growth, predispose girls to chronic anemia and increase their risk of maternal hemorrhage. Women over 35 “Maleka was 45 years old when she became pregnant with her seventh child. She considered the possibility of having an abortion, but discarded the idea for fear her husband would find out. Such was her shame and despair that she didn’t inform anyone – not even her daughters – until she was quite far along. Her pregnancy was a difficult one. Her hands and legs swelled with edema and in her eighth month, Maleka’s entire body ballooned. Minara, her daughter, was beside herself with anxiety and called in the services of a dai – the Bengali term for traditional birth attendant. She wanted to take her mother to the hospital but the dai reassured Minara that her mother was fine and the situation under control. Minara was not convinced and ran to the nearest phone booth to call an ambulance. When she returned the dai informed her that her mother had delivered and that all was well – despite the fact that Maleka continued to bloat and appeared weaker than ever. Ten days following her delivery, Maleka was still ailing. After many entreaties and tears the family finally agreed to take their delirious daughter-in-law to the hospital, where she was promptly put on saline. By then Maleka was so ill she could not speak. When the convulsions started, Minara screamed for the nurse who, not realizing the seriousness of the situation, scolded the distraught girl for being noisy. As night fell Maleka slid into a troubled coma. She never woke up.” — Source: Minara Begum, UNICEF For older women, age coupled with other factors – such as the number of preceding births and how closely they are spaced – drives mortality rates even higher than those experienced by younger women. 17 Closely Spaced Pregnancies “Ahila Bala lived in Kamar Para in Chirirbandar of Dinajpur district with her day laborer husband, her only living child and her husband’s parents. Because her husband earned less than U.S. $20 per month the family had to scramble for food and were forced to subsist on a woefully inadequate ration of one meal per day. Ahila Bala’s life had always been hard. Given into marriage at the age of 14, her low caste Hindu parents were too poor to send her to school and considered her a burden. A local religious leader suggested that they marry her off. A grown-up daughter living at home was considered not only a financial liability but also a black mark against the family honor. At the age of 18, she had already given birth three times. Owing to Ahila’s young age, ill health
and chronic malnutrition, each child was born underweight and proved too weak to survive – with the exception of one. When she again found herself pregnant, Ahila decided to heed the urging of a local community volunteer, defied her in-laws and sought prenatal counseling at a local clinic. Health care workers found Ahila to be extremely anemic and referred her to a nearby hospital. She did not go. On March 6, attended by a traditional birth attendant and her paternal aunt, Ahila delivered yet another baby. Passing the placenta however was quite another matter. After more than one and a half hours, the anxious birth attendant entreated Ahila’s husband to take her to the hospital, whereupon Ahila looked up pleadingly and told them she was afraid she would not make it. She died a few moments later.” — Source: Dr. Shehlina Ahmed, Health Advisor, PLAN International Bangladesh Pregnancy and childbirth are hard on the body. For any woman, the chances of serious injury, illness or even death increases exponentially after the birth of her third child. This is because frequent pregnancy, childbirth and breastfeeding deplete women’s physical resources and stamina, making it more difficult for them to fight the effects of blood loss, infection or trauma during or after childbirth. WHO maintains that women who have given birth to five or more children are two to three times more likely to die during pregnancy or childbirth than those who have been able to limit their families to two or three children.18 Women who are already ill Another primary indicator of maternal mortality is poor health on the part of the mother. Malaria, tuberculosis, iron-deficient anemia and the ever-widening threat posed by HIV/AIDS are just a few of the conditions that predispose mothers to problems during pregnancy and birth. According to medical experts, women who are HIV-positive during pregnancy are more likely to suffer severe antenatal and postnatal complications with a higher mortality rate from puerperal sepsis and other complications.19 In Africa today, women make up more than half of those newly infected with HIV. There is little indication that these numbers will decline anytime soon. 20 Although female-controlled methods of preventing infection are now available, their cost is prohibitive and their use still involves negotiation with a male partner. Vaginal microbicides – gels or creams that kill the virus on contact – are still in the development phase and have not been approved for widespread use. Unsafe abortion “She was semi-conscious. Some children playing near her house saw blood coming from her room and ran to alert the neighbors. When they opened the door, they found her lying in a pool of her own blood – so much of it – and she was brought to our clinic by the neighbors. Her name was not known. We at once began resuscitating her. We gave her hydrocortisone, oxygen and dextrose because she was bleeding, bleeding, bleeding. We gave her intravenous fluids. We removed a lot of clots and gave her ergometrine, raised the foot of her bed and sent for the ambulance, which took 40 minutes to arrive. By this time our patient had improved a little and told us her name was Muthoni and that she was the mother of three children. We prayed with the patient. She asked for water – ‘maji’. This is a bad sign, a sign of danger. I did not know whether to insert a speculum – there were so many clots. When the ambulance arrived, a nurse from the facility accompanied her to Kenyatta Memorial Hospital. Her last words were ‘mama yangu’ (my mother), ‘watoto wangu’ (my children) and ‘mungu nisamehe’ (God forgive me). Instead of being taken to the hospital, she was taken to the mortuary.” — Source: Midwife Evelyn Mutio describes the death of a 23-year-old mother of three following a botched abortion The World Health Organization defines unsafe abortion as follows:
Unsafe abortions are characterized by the lack or inadequacy of skills of the provider, hazardous techniques or unsanitary facilities. Although the legality or illegality of the services may not be a defining factor of their safety, for the purpose of these tabulations, unsafe abortion has been defined as an "abortion not provided through approved facilities and/or persons." What constitutes approved facilities and persons will vary according to the legal and medical standards of each country. The definition does not take into consideration the differences in quality, services available or the other substantial differences between health systems. 21 According to the data analyzed in this report, deaths as a result of unsafe abortions account for 64 percent of the 687,000 women who have died as a result of unintended pregnancies since 1995. Contrary to popular stereotypes, the vast majority of women seeking abortions are married and caring for a number of children already. They may seek out abortion services to limit their family, space births, and address contraceptive failure. Most often they undergo abortion because they are unable to access dependable family planning services. In regions of the world where access to affordable and effective contraception remains limited or nonexistent, women often undergo selfinduced or unsafe abortions. Abortion – whether medical or surgical – when carried out under careful clinical guidelines and with trained personnel, carries the lowest physical risks for women of any significant medical intervention. A procedure that is low risk in the developed world, however, is often fraught with dangers in the frequently unsanitary conditions endemic in the developing world. Current studies show that women living in sub-Saharan Africa still face the greatest risk of mortality owing to unsafe abortion. One of every 150 abortions ends in the death of the woman – as opposed to one in 85,000 procedures undertaken in the developed world.22 The Global Health Council’s statistical analysis corroborates these figures (see Table Four, p. 16). Despite this stark scenario, many women continue to opt for abortion out of sheer desperation. Women may attempt to induce abortion themselves, or may rely on the services of untrained nonmedical personnel or health workers operating in unhygienic conditions. Methods range from the insertion of sharp objects into the uterus, ingestion of noxious substances, to incomplete dilatation and curettage or external force, such as deep and prolonged abdominal massage. This analysis has revealed yet another reason why women may continue to subject themselves to the risks associated with abortion. In every geographic region of the world the risk of maternal death from abortion was found to be lower than the risk of maternal death from a pregnancy carried to term (see Table Six, p. 30). From a global perspective risk of death was more than twice as great for a woman delivering a child than for abortion. While this discrepancy was hardly surprising in the clinical conditions of economically developed countries, it is particularly striking that it was also evident in Africa and Asia. It is the very women traditionally deprived of effective preventive family planning methods who are most likely to risk abortion in the absence of any other alternative. Theirs is a multiple bind: they can neither prevent their pregnancies nor terminate them safely – but neither can they be confident of surviving childbirth, delivering healthy babies or supporting their children once they are born. “Shafikun was 35 years old and very poor when she realized she was pregnant with her seventh child. Her previous six children were all grown and she felt so ashamed and embarrassed she decided to risk an abortion. During her fourth month, Shafikun quietly inserted a herbal root into her uterus in the hopes that it would trigger a miscarriage. Soon after the bleeding began, she suddenly collapsed into convulsions and died soon after.” — Source: Taslima Begum, UNICEF Bangladesh The risk of maternal mortality during abortion depends largely on the skill of the practitioner, the method used, the risks of infection and the general health of the woman involved. The presence of sexually transmitted diseases, anemia, malaria, HIV/AIDS, the woman’s age and the phase at
which the abortion is performed all contribute to potential complications. These include sepsis, hemorrhage, genital and abdominal trauma, perforated uterus, poisoning and secondary complications such as gangrene or acute renal failure. Researchers estimate that for every woman who dies as a result of unsafe abortion, 30 more will suffer chronic disability.23 Chronic pelvic pain, pelvic inflammatory disease (PID), tubal occlusion and secondary infertility are just a few of the long-term chronic conditions that may afflict women who survive unsafe abortion. Typical multiple complications from illegally induced abortion are reported in a 1989 study of 840 patients in Ibadan, Nigeria.24 These are: sepsis (86 percent), hemorrhage (35 percent), uterine perforations (16 percent), lower genital tract injury (10 percent), renal failure (0.4 percent), embolism (0.2 percent). Of the 840 patients admitted for complications, 59 died. Access to safe and reliable contraception would go a long way towards preventing these women from risking their lives at the hands of unsafe, unskilled practitioners working in unsanitary conditions. By providing women with the means to avoid unintended pregnancy, family planning services prevent abortions and save lives. “One morning during a visit to one of my weaving groups, I noticed the absence of one of the best weavers. I asked where she was. The government worker assigned to the group replied that she had died two days earlier from a massive hemorrhage resulting from an attempted abortion. She was in her early twenties and already had five children. Abortion in Togo, at this time and also currently, was illegal and safe procedures were unavailable.” — Source: Suzanne Marks, former Peace Corps volunteer Gender-based violence “I punished her by beating with a cane and like, three or four slaps. It is a must that I remain firm as father of the family. I am head of the household.” — Male (45-years old) Tanzania — Source: Population Council, Horizons, HIV and Partner Violence, 2001 Systematized gender bias leads to exploitation on many fronts, but by far the most destructive manifestation is sexual and physical abuse. Gender-based violence is strongly associated with high maternal mortality rates. According to WHO, between 10 and 50 percent of women are violently abused by an intimate partner at least once during their lifetime. “Shahida is the mother of seven children. Within days of giving birth to her third child, she and her husband got into an argument during which he kicked her in the abdomen, knocked her down and then jumped up and down on her stomach. Because she did not want to alarm her children, Shahida bit her lip and kept silent while he kicked her over and over again. That night, while urinating she felt the ligaments holding her uterus give way and the organ slip out. She could even touch it. From that point onward, Shahida has suffered from what is known as prolapsed uterus. Shahida has given birth to four more children since that time. Each pregnancy and delivery has been characterized by an almost inconceivable agony. Her life has become a thing of continued misery. She can neither lift anything heavy – including her children – nor sit down comfortably because her uterus is likely to slip out and she must suffer the humiliation of trying to press it back with her fingers. When clothing sticks to the organ, attempts to pull it off invariably trigger yet another round of bleeding. Sex with her husband is likewise fraught with pain and accompanied by the dread that she will again get pregnant and perhaps die as a result.” — Source: Suchitra Mallik, CARE Bangladesh Population Action International defines gender-based violence as female infanticide, incest, rape, child abuse, prostitution and harmful traditional practices such as forced early marriage, and genital mutilation.25 The latter – a painful, dangerous and disabling procedure visited on an estimated two million African girls every year – is an important cause of maternal mortality, as well as a major factor in the spread of HIV/AIDS. Physical abuse, moreover, is frequently accompanied
by sexual abuse, which in turn contributes to increased rates of unwanted pregnancy. In addition, it increases the likelihood that the victim will be exposed to sexually transmitted diseases, including HIV, hepatitis B and a host of other infectious diseases. A 1999 study in Uttar Pradesh, India, found that women married to abusive husbands were more likely to have unplanned pregnancies and suffer from higher rates of sexually transmitted infections.26 Researchers determined that fear of violence prevented these women from negotiating sex or demanding that their abusive spouses wear condoms. Along the same lines, a Population Council study undertaken in Dar es Salaam, Tanzania, revealed that 39 percent of HIV-positive female respondents had been the victims of physical abuse, while 17 percent had had at least one partner who had been sexually abusive. Without adjusting for other variables, researchers concluded that HIV-positive women were more than 2.8 times more likely than HIV-negative women to have experienced a violent episode with a current partner. 27 Despite the extreme forms gender-based abuse can take, as with every other indicator of maternal mortality, violence against women speaks to a wider and more deeply entrenched problem relating to the subordinate status of women in many societies.
13 Save the Children, State of the World’s Mothers, 2000, p.19. 14 Population Reference Bureau, Population Today, Washington, D.C., March 1998. 15 Alan Guttmacher Institute, Support for Family Planning Improves Women’s Lives, 1998. 17 Walsh JA, Feifer CN, Measham AR, Gertler PJ, Maternal and Perinatal Health; In Jamieson DT, Mosely WH, Measham AR, Bobadilla JL, Disease Control Priorities in Developing Countries, Oxford University Press, New York, 1993, pp. 363-390. 18 WHO, Unsafe Abortion, 1997, p. 3. 19 JE Wiebenga, Maternal Mortality at Queen Elizabeth Central Hospital, Malawi Medical Journal, 1989-1990. 20 UNAIDS, 2001. 21 WHO, Unsafe Abortion, 1997, p. 3. 22 Population Action International, A World of Difference, 2000, p. 7. 23 Ibid. 24 WHO, Unsafe Abortion, Global and Regional Estimates of Incidence of and Mortality Due to Unsafe Abortion, 1997, p. 3 25 Population Action International, A World of Difference, 2000. 26 Ibid. 27 Population Council, Horizons, HIV and Partner Violence: vol. 7, 2000.
“Nadzua Kache belongs to the Duruma tribe of coastal Kenya where she lives with her husband and two children. The region she calls home is arid, harsh and the people who live there eke out a meager existence, harvesting maize and whatever else they can scratch from the hostile soil. Because the area is so poor, literacy is low and the resultant traditional culture is bound by ignorance, taboos and strictures that virtually guarantee ill health, particularly for women. For the average Duruma male, family planning is considered an invitation for female promiscuity. In order to maintain the respect of family and community, proprietorial mothers-in-law and unskilled traditional birth attendants further propagate this deep-rooted belief with the result that women are expected to bear as many children as there are "eggs" in her belly. In keeping with this uncompromising attitude, delivering in a hospital is considered "cowardly," and a man whose wife requires such services is sneered at and ridiculed. Angry and humiliated, the husband in question will frequently withhold postnatal support to punish his "weak" wife. Instead of having a goat or a chicken slaughtered in celebration, the new mother must forage for vegetables in the family plot for herself and her newborn child. Community disapproval and censure compel most expectant mothers to risk a home birth despite the obvious dangers. It was in this uncompromising environment that Nadzua began her third labor. Relying on the advice of her local midwife, Nadzua had forfeited all high-protein foods including milk, eggs and meat, so that the baby, "would not become so big and cause problems during delivery." As was typical among her people, Nadzua was still expected to till the fields under the supervision of her husband in order to provide food for both him and "her children." Because she did not have a daughter and field work is not among the "listed" tasks for men, Nadzua toiled alone in the fields, fetched firewood, cooked and provided all means of support for her family. She was the first to rise and the last to go to bed at night. As with her other pregnancies, Nadzua was determined to prove her courage to her husband and quietly acquiesced to a home birth. After hours of agonizing labor, orders from her traditional birth attendant and a gaggle of local female elders to "push harder," coupled with threats by her husband that he would discipline her if she continued "withholding delivery," Nadzua brought forth her baby. The child however, was dead – most likely the casualty of seven hours of futile pushing. Little did anyone know that Nadzua was pregnant with twins – this time the second baby was presenting elbows first. A TBA, trained by the Agha Khan Health services, was sent for and upon arrival immediately declared that Nadzua should never have been forced into a home birth and that she should be sent to the dispensary immediately. She also warned that Nadzua was in great danger of losing the second child and indeed, her own life because she was exhausted from the pointless suffering of the first delivery. Upon arrival at the dispensary, the on-duty nurse quickly examined Nadzua and announced that she needed a Caesarean section – something that could only be undertaken at the nearest hospital fully 60 kilometers away. With no public transport available at that hour of the day, and too poor to afford it in any case, the husband had no means to transport his anguished wife to the hospital. Fortunately a team from the Kenya chapter of the Agha Khan Health Services showed up to deliver a message on their way to the city. Their truck was converted into a makeshift ambulance and Nadzua was successfully transported to the district hospital where she underwent lifesaving surgery. Sadly however, the second baby was also stillborn and to this day her husband condemns her for "wasting his babies." If the same thing happens again, he swears he will divorce her and marry another.” For Nadzua, her double loss has been compounded by a deep sense of powerlessness and despair. Despite the well-intentioned advice of family planning counselors warning of the dangers of conceiving so soon after her last traumatic pregnancy, the odds are stacked against her. With no authority to defy her husband and go on birth control, nor to refuse him, Nadzua will likely conceive soon and continue to do so until all the "eggs in her are exhausted." Chances are she will not survive her next pregnancy.
— Source: Fred M. K’ung, Information Office, Agha Khan Health Services, Kenya
Women in society Although the causes of maternal mortality are complex, they are clearly linked to the continued low status of women in many regions of the world. Deprived of adequate food, medical care, education and the corresponding means to acquire economic independence, many women in the highest risk nations are unable to demand quality healthcare and access to contraception. For the hundreds of thousands of women who die of maternal causes each year, premature death is the final step in a long continuum of deprivation, discrimination and pain. For the many more women damaged and disabled by inadequate care, ignorance and poverty, physical trauma is compounded by an inability – through no fault of their own – to meet the often harsh and unrelenting expectations of family and community. This marginalization is manifested in a variety of ways according to region, custom and socioeconomic status. Seventy percent of the world’s most impoverished people are women.28 In studies undertaken in Asia, researchers found that most parents routinely fed their female children 16 percent less than male siblings – predisposing them to infectious diseases, malnutrition and greater maternal risk once they reach their childbearing years. Girls are frequently last to receive both medical attention and education. In most developing countries, female literacy lags well behind male literacy; 80 percent of women in sub-Saharan Africa, for example, are deprived of even the most basic education. Illiterate women marry younger, have babies earlier and are often unable to fend for themselves economically nor can they participate in public life. A joint statement on safe motherhood, released in 1999 by WHO, the United Nations Population Fund (UNFPA), the United Nations Children’s Fund (UNICEF) and the World Bank, acknowledges that: The low social status of women in developing countries is an important factor underlying maternal mortality. Low social status limits women’s access to economic resources and basic education, impeding their ability to make important decisions on childbearing, health and nutrition.29 Without knowledge of reproductive alternatives, women cannot demand what has become a recognized right for women and men living in industrialized nations: namely, to be informed and to have access to safe, effective, affordable and effective methods of family planning of their own choosing.30 28 World Bank Annual Report, 1995. 29 Joint WHO/UNFPA/UNICEF/World Bank Statement, 1999. 30 ICPD Programme of Action, 1994.
CHAPTER FIVE
CONCLUSION In 1994, the nations of the world met in Cairo and pledged to improve the reproductive health of the world’s women. Yet during the six years that followed, nearly 700,000 women died simply because they could not obtain basic services required to prevent pregnancies they did not wish to bear. Had their wishes been honored – had they not become pregnant – they would have lived. Tens of millions more did live, but were forced to bear the consequences of pregnancies that were too much for their bodies. Access to family planning and reproductive health services would not have taken away their poverty nor the conditions of life in which they must daily struggle – but it would have given them a chance. Family planning is about preventing needless deaths. It is also about empowering women, their partners and their families to make choices about how many children to have, when to have them, and when to stop. Family planning is not a political term but a medical one: it is a means of identifying and addressing concerns – including health concerns – related to pregnancy and maternity. Countries that fail to provide adequate resources in this area risk provoking the very thing we all seek to avoid – pointless deaths, shattered families and unnecessary suffering. Today, at the start of a new century and a new era of medical breakthroughs, too many women are still dying from causes that were all but vanquished from the industrialized world half a century ago. The divide stretches not only between rich and poor, industrialized and developing, but also between social and cultural expectations and the painful realities that most women live and die with every day, every hour, and every minute, all over the world. The freedom to choose how many children to bring into the world and when to do so is a right that many take for granted. The same is not true for the vast majority of women living in impoverished and socially disadvantaged circumstances around the world. Theirs remains a grim choice between the lesser of two evils: to carry an unwanted child to term and face ill health, economic want, truncated opportunities for their other children, and even death, or to risk almost exactly the same disastrous consequences through unsafe abortion. The purpose of this analysis was to examine to what degree the global community has lived up to commitments made to the world's women in Cairo in 1994. The results detailed here – of steady or even rising death rates owing to unintended and unwanted pregnancies – speak to the responsibility of governments to furnish services pledged to their citizens. It also calls for governments of affluent countries to assure that means be made available to support those essential services. As the world’s wealthiest and most powerful country, it is also fair to ask why the United States provided nearly 30 percent less support for these efforts in 2000 than it did in 1994. No woman should die trying to become a mother. Nor should any woman die for want of decent reproductive health care that is effective and should be cheaply available around the world. The International Conference on Population and Development represented an important rhetorical step forward in the achievement of women’s reproductive health. This analysis, however, indicates that the world’s rhetoric has yet to translate into reality: women and their families are still suffering from the effects of pregnancies that they can
neither physically nor economically support, and many are paying for that fact with their lives. If we are to keep the promises made to the world’s women, we have miles to go before we sleep.